In A Theory of Justice (1971), John Rawls viewed the interests and concerns of people with disabilities as beyond the pale of justice, at best requiring that ad hoc or “special” measures be added onto policies designed for “normal” people. Happily, these days theorists of distributive justice treat disability not as an outlier but as a litmus test of theoretical adequacy. In his superb book, Mark Stein follows this path, but with the specific purpose of pitting utilitarianism against egalitarianism. It is when these competing theories deal with disability, he argues, that we notice how much they diverge, and more to the point, how and why it is that utilitarianism is superior.
Relying on hypothetical examples to test our intuitions, Stein argues that an egalitarianism that strives to equalize material resources will be unable to provide the extra medical resources people with disabilities require, whereas an egalitarianism that seeks to equalize welfare will be pulled in the opposite direction and massively redistribute social resources to a few, especially disadvantaged, persons with disability. By contrast to resource and welfare egalitarianism, utilitarianism offers a “golden mean” that redistributes fairly. It can do so because utilitarianism is the only distributive theory that always, and only, relies on the “greater benefit criterion,” namely, that resources should be distributed to those who would most benefit from them in terms of increased welfare.
After demolishing generic versions of resource and welfare egalitarianism, Stein turns to the specific distributive accounts of Rawls, Ronald Dworkin, and Bruce Ackerman (representing resource egalitarians), then to theorists who use both utilitarian and welfare egalitarianism as distributive principles—such as Amartya Sen, Gerry Cohen, Norman Daniels and Martha Nussbaum—and then finally to prioritarians who, in effect, combine utilitarianism and welfare egalitarianism.
In such a short—and very readable, even entertaining—book, Stein's coverage of the field is admirable. The beauty of his argumentation lies in the examples on which he relies. Throughout the book, his argumentative strategy is to show that theories get it wrong when they ignore the relative benefit of resources, and get it right only when they mimic, or simply incorporate, the utilitarian distributive criteria of maximizing relative benefit. And on those rare occasions when utilitarianism produces intuitively troubling results, he argues, you can be sure egalitarianism would yield even more troubling results.
As often happens with a book that is pellucid in presentation, precisely argued, and unpretentious, it is easy enough to find points with which to disagree. Tinkering with the details, while certainly a temptation, presumes that Stein has set out the problem correctly. But there is reason to think he has not. For Stein begins and ends with a conceptually anemic understanding of the concept of disability, one that makes his job much easier, but only at the risk of distorting both the notion and the lived experience of disability. He is not alone in this, but in his case it threatens to shake the foundations of his argument.
Stein suggests that, for his purposes, disabilities are “health-related conditions that might be expected to reduce welfare” (p. 23). The definitional link to reduced welfare obviously plays directly into his “greater benefit criterion” (and probably makes resource egalitarianism implausible ab initio); but that is not the real concern. The problem is that what he is capturing here is not disability but a component dimension of disability that goes by the name of “impairment.” Impairments are functional limitations or health decrements; disability is something far more complex. Disability is the outcome of interactions between impairments and a person's physical, attitudinal, and social environment (see World Health Organization's International Classification of Functioning, Disability and Health, 2001). Disability is how impairments actually play out in a person's life.
So understood, disability is certainly associated with disadvantage, but not so much because of the underlying impairment. The bulk of the disadvantage is produced by social attitudes that stigmatize and exclude, by the built environment that makes it difficult or impossible for people with mobility impairments to get around, go to school, or hold down jobs, by social policies that ignore the need for accommodation and integration, and on and on.
Stein very briefly acknowledges this more robust view of disability, but quickly says it does not matter to his account (p. 37). But it makes a world of difference. Focusing on the health deficit of disability distorts the analysis in a variety of ways.
As it happens, many people, even with severe functional limitations, incur no more medical costs than the average person. Moreover, making the blind see or quadriplegics run marathons is not what justice requires. Yet, since he restricts the disadvantage of disability to the medical sphere, this is precisely what Stein assumes. The “cure or amelioration” of disability (either in fact, or through compensation when impossible) is the aim of social justice. This points us in the wrong direction. Since impairment is not the sole, or even the major, source of the disadvantage of disability, cure or amelioration are not what justice requires. These goals distort the analysis since they immediately lead us to putative, but wildly counterintuitive, resource and welfare egalitarian demands, of the sort that the author happily uses to his advantage in his overall argument.
Secondly, the causes of the disadvantage of disability include social arrangements that are mutable and for which, arguably, we are all responsible. Impairments may be the result of “brute luck,” but the failure to accommodate functional limitations is not. More to the point, most of these social changes need not require the redistribution of staggering amounts of social resources. They may require change of attitudes, stereotypes, and other misperceptions, and they will certainly require political will and a reorientation of social planning. But none of this is simply a matter of moving resources around.
Altering social perceptions to respond to disability may, indeed, save money and social resources. Proponents of Universal Design insist that the built environment can be designed to accommodate a wide spectrum of functional capacities, not just the normal range. If, rather than spend whopping sums of money retrofitting our built environment, we design and build for a more realistically varied population of users, we will increase usability and save money in the long run.
Lastly, Stein's characterization of disability forces him to confront an application of utilitarianism in the allocation of medical resources that is associated with Peter Singer (and worked out in detail by Peter Ubel in Pricing Lives, 1999). Because disability lowers welfare, the argument goes, a cost–welfare comparison between a normal person needing a new kidney and a person with a severe disability who also needs a kidney will favor the normal person, since we get more bang for our medical buck. Stein tries to duck the problem by suggesting that a policy of devaluing disabled lives would cause insecurity and social unrest, and so would not be an appropriate utilitarian option. But a far better response is that the belief that disability creates a massive welfare deficit is itself a social prejudice, not a medical fact.
Despite the trouble that Stein's conflation of impairment and disability causes, he is an able philosopher and might be able to recast his arguments against egalitarianism in light of a more realistic conception of disabilty. In any event, this is a sophisticated and well-thought-out book, and he has certainly elevated the discussion.
